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Summary of Medical Beneits (continued)
Aetna HSA 1350
Plan Features In-Network Out-of-Network
Calendar Year Deductible
(the amount you must pay before the plan starts paying $1,350 Individual $2,700 Individual
beneits, includes medical and pharmacy) $2,700 Family $5,400 Family
No one in the family is eligible for beneits until the family
coverage deductible is met
Calendar Year Out-of-Pocket Maximum
(Medical and Pharmacy; Includes copay, deductible and $2,500 Individual $5,000 Individual
coinsurance) $5,000 Family $10,000 Family
If more than one person in a family is covered under the policy,
the single out-of-pocket maximum stated above does not apply
Lifetime Maximum Unlimited
Doctors’ Ofice Visits
Primary Care Physician (PCP)/Specialist visit 80% after deductible 60% after deductible
Preventive Care (well-baby, well-child, adult and well- 100%, 70% after deductible
woman: including immunizations) deductible does not apply
Chiropractic Care/Physical Therapy (60 visits per year 80% after deductible 60% after deductible
per member)
Maternity
> Visit to conirm pregnancy/Specialist 80% after deductible 60% after deductible
> Prenatal, Delivery and Postnatal* 80% after deductible 60% after deductible
Hospital—Inpatient Stay 80% after deductible 60% after deductible **
Outpatient Surgery 80% after deductible 60% after deductible**
Emergency Care
Emergency Health Services/Urgent Care Facility 80% after deductible 80%/70% after deductible
Ambulance Services—Emergency only 80% after deductible 80% after deductible
Infertility Services †† 80% after deductible 60% after deductible
Mental Health and Substance Abuse Services— 80% after deductible 60% after deductible**
Outpatient
Mental Health and Substance Abuse Services— 80% after deductible 60% after deductible**
Inpatient and Intermediate
Acupuncture (100 visits per year per member) 80% after deductible 60% after deductible
Prescription Drugs
Retail (30-day supply) Deductible then Deductible then 20% of submitted
> Tier 1/Tier 2/Tier 3 $10/$30/$60 cost; after applicable copay
Mail Order (90-day supply)
> Tier 1/Tier 2/Tier 3 $25/$75/$125 Not applicable
* Notiication is required if inpatient stay exceeds 48 hours following a normal vaginal delivery or 96 hours following a cesarean section delivery.
** Prior authorization is required.
†† Diagnosis and treatment of the underlying medical condition only. Coverage includes artiicial insemination and ovulation induction limited to six
courses of treatment combined, per member lifetime. Coverage includes artiicial insemination and ovulation induction limited to six courses of treatment
combined, per member lifetime. ART coverage includes: In vitro fertilization (IVF), zygote intrafallopian transfer (ZIFT), gamete intrafallopian transfer
(GIFT), cryopreserved embryo transfers, intracytoplasmic sperm injection (ICSI) or ovum microsurgery. Limited to $25,000 in member’s lifetime. Lifetime
maximum applies to all procedures covered by any of our plans except where prohibited by law. Additional coverage for embryo and sperm cryopreservation
or storage of cryopreserved embryos and sperm for all members who are eligible for IVF.
Note: This medical plan summary provides only highlights of these beneits. Please refer to the oficial plan documents or Summary Plan Description, or
contact your People Team Representative for speciic terms and conditions, including limitations and exclusions.
6
Aetna HSA 1350
Plan Features In-Network Out-of-Network
Calendar Year Deductible
(the amount you must pay before the plan starts paying $1,350 Individual $2,700 Individual
beneits, includes medical and pharmacy) $2,700 Family $5,400 Family
No one in the family is eligible for beneits until the family
coverage deductible is met
Calendar Year Out-of-Pocket Maximum
(Medical and Pharmacy; Includes copay, deductible and $2,500 Individual $5,000 Individual
coinsurance) $5,000 Family $10,000 Family
If more than one person in a family is covered under the policy,
the single out-of-pocket maximum stated above does not apply
Lifetime Maximum Unlimited
Doctors’ Ofice Visits
Primary Care Physician (PCP)/Specialist visit 80% after deductible 60% after deductible
Preventive Care (well-baby, well-child, adult and well- 100%, 70% after deductible
woman: including immunizations) deductible does not apply
Chiropractic Care/Physical Therapy (60 visits per year 80% after deductible 60% after deductible
per member)
Maternity
> Visit to conirm pregnancy/Specialist 80% after deductible 60% after deductible
> Prenatal, Delivery and Postnatal* 80% after deductible 60% after deductible
Hospital—Inpatient Stay 80% after deductible 60% after deductible **
Outpatient Surgery 80% after deductible 60% after deductible**
Emergency Care
Emergency Health Services/Urgent Care Facility 80% after deductible 80%/70% after deductible
Ambulance Services—Emergency only 80% after deductible 80% after deductible
Infertility Services †† 80% after deductible 60% after deductible
Mental Health and Substance Abuse Services— 80% after deductible 60% after deductible**
Outpatient
Mental Health and Substance Abuse Services— 80% after deductible 60% after deductible**
Inpatient and Intermediate
Acupuncture (100 visits per year per member) 80% after deductible 60% after deductible
Prescription Drugs
Retail (30-day supply) Deductible then Deductible then 20% of submitted
> Tier 1/Tier 2/Tier 3 $10/$30/$60 cost; after applicable copay
Mail Order (90-day supply)
> Tier 1/Tier 2/Tier 3 $25/$75/$125 Not applicable
* Notiication is required if inpatient stay exceeds 48 hours following a normal vaginal delivery or 96 hours following a cesarean section delivery.
** Prior authorization is required.
†† Diagnosis and treatment of the underlying medical condition only. Coverage includes artiicial insemination and ovulation induction limited to six
courses of treatment combined, per member lifetime. Coverage includes artiicial insemination and ovulation induction limited to six courses of treatment
combined, per member lifetime. ART coverage includes: In vitro fertilization (IVF), zygote intrafallopian transfer (ZIFT), gamete intrafallopian transfer
(GIFT), cryopreserved embryo transfers, intracytoplasmic sperm injection (ICSI) or ovum microsurgery. Limited to $25,000 in member’s lifetime. Lifetime
maximum applies to all procedures covered by any of our plans except where prohibited by law. Additional coverage for embryo and sperm cryopreservation
or storage of cryopreserved embryos and sperm for all members who are eligible for IVF.
Note: This medical plan summary provides only highlights of these beneits. Please refer to the oficial plan documents or Summary Plan Description, or
contact your People Team Representative for speciic terms and conditions, including limitations and exclusions.
6
